Provider Demographics
NPI:1376842732
Name:WALLACE, SUSAN ELIZABETH (R,D, LD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:WALLACE
Suffix:
Gender:F
Credentials:R,D, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 CARRAN DR
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE PARK
Mailing Address - State:KY
Mailing Address - Zip Code:41017-2233
Mailing Address - Country:US
Mailing Address - Phone:859-331-2939
Mailing Address - Fax:
Practice Address - Street 1:102 CARRAN DR
Practice Address - Street 2:
Practice Address - City:LAKESIDE PARK
Practice Address - State:KY
Practice Address - Zip Code:41017-2233
Practice Address - Country:US
Practice Address - Phone:859-331-2939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-23
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-1998133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered